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Form 17-1a Academic Year: 2017-18

Student-Athlete Statement NCAA Division I

For: Student-athletes.
Action: Sign and return to your director of athletics.
Due date: Before your first competition each year.
Required by: NCAA Constitution 3.2.4.6 and NCAA Bylaw 12.7.2.
Purpose: To assist in certifying eligibility.
Effective Date: This NCAA Division I Student-Athlete Statement shall be in
effect from the date this document is signed and shall remain in
effect until a subsequent Division I Student-Athlete Statement
form is executed.

Student-athlete:
(Please print name)
The completion of this form is required to participate in intercollegiate competition.

This form has six parts:

I. A statement concerning eligibility;

II. A Buckley Amendment consent;

III. An affirmation of status as an amateur athlete;

IV. Results of drug tests;

V. Previous involvement in NCAA rules violation(s); and

VI. An affirmation of valid and accurate information provided to the NCAA Eligibility Center and
admissions office, including ACT or SAT scores, high school attendance, completion of
coursework and high school grades.

This form must be completed and signed before participation in intercollegiate competition. Please
note, only incoming transfers and continuing student-athletes must complete Part V. Only incoming
freshmen student-athletes must complete Part VI.

Before you sign this form, you should read the Summary of NCAA Regulations, or another outline
or summary of NCAA legislation, provided by your director of athletics (or his or her designee) or
read the bylaws of the NCAA Division I Manual that address your eligibility. You are responsible
for knowing and understanding the application of all NCAA Division I bylaws related to your
eligibility. If you have any questions, you should discuss them with your director of athletics or
your institution's compliance officer, or you may contact the NCAA at 317-917-6222.
Student-Athlete Statement Division I
Form 17-1a
Page No. 2
_________

The conditions that you must meet to be eligible and the requirement that you sign this form are
indicated in the following bylaws of the Division I Manual:

NCAA Bylaws 10, 12, 13, 14, 15, 16, 18.4 and 31.2.3.

Part I: Statement Concerning Eligibility.

By signing this part of the form, you affirm the following:

Your institution has provided you a copy of the Summary of NCAA Regulations, or another outline
or summary of NCAA legislation, or the relevant sections of the Division I Manual and that your
director of athletics (or his or her designee) gave you the opportunity to ask questions about them.

You have knowledge of and understand the application of NCAA Division I bylaws related to
eligibility, recruitment, financial aid, amateur status and involvement in sports wagering activities.

You are aware of the NCAA drug-testing program and that you have signed or will sign the current
NCAA Drug-Testing Consent Form.

All information provided to the NCAA, the NCAA Eligibility Center and the institution's
admissions office is accurate and valid, including ACT or SAT scores, high school attendance,
completion of coursework and high school grades, as well as your amateur status.

You have reported to your director of athletics (or his or her designee) any violations of NCAA
regulations involving you and your institution.

You affirm that you understand that if you sign this statement falsely or erroneously, you violate
NCAA legislation on ethical conduct and you will further jeopardize your eligibility.

____________________
Name (please print) Date of birth Age

Signature of student-athlete Home address (street or P.O. Box)

____________________________
Date Home city, state, and zip code

Sport(s)
Student-Athlete Statement Division I
Form 17-1a
Page No. 3
_________

Part II: Buckley Amendment Consent.

By signing this part of the form, you certify that you agree to disclose your education records.
You understand that this entire form and the results of any NCAA drug test you may take are part of
your education records. These records are protected by the Family Educational Rights and Privacy
Act of 1974 and they may not be disclosed without your consent.
You give your consent to disclose only to authorized representatives of this institution, its athletics
conference (if any) and the NCAA, except as permitted in the Drug-Testing Consent form, the
following documents:

1. This form;

2. Results of NCAA drug tests and related information and correspondence;

3. Results of positive drug tests administered by a non-NCAA national or international sports


governing body;

4. Any transcript from your high school, this institution or any junior college or any other
four-year institution you have attended;

5. Precollege test scores, appropriately related information and correspondence (e.g., testing
sites, dates and letters of test-score certification or appeal) and, where applicable, information
relating to eligibility for or conduct of nonstandard testing;

6. Graduation status;

7. Your social security number and/or student identification number;

8. Race and gender identification;

9. Diagnosis of any education-impacting disabilities;

10. Accommodations provided or approved and other information related to any


education-impacting disabilities in all secondary and postsecondary schools;

11. Records concerning your financial aid; and

12. Any other papers or information pertaining to your NCAA eligibility.


Student-Athlete Statement Division I
Form 17-1a
Page No. 4
_________

You agree to disclose these records only to determine your eligibility for intercollegiate athletics,
your eligibility for athletically related financial aid, for evaluation of school and team academic
success, for awards and recognition programs highlighting student-athlete academic success (e.g.,
Elite 90), for purposes of inclusion in summary institutional information reported to the NCAA (and
which may be publicly released by it), for NCAA longitudinal research studies and for activities
related to NCAA compliance reviews and institutional performance program. You will not be
identified by name by the NCAA in any such published or distributed information. This consent
shall remain in effect as long as any issues regarding the purposes listed above exist.

You also agree that information regarding any infractions matter in which you may be involved may
be published or distributed to third parties as required by NCAA policies, bylaws or procedures.

Name (please print)

Signature of student-athlete Date

Signature of parent or legal guardian (if student-athlete is a minor) Date

Part III: Affirmation of Status as an Amateur Athlete.

You affirm that you have read and understand the NCAA amateurism rules.

By signing this part of the form, you affirm that, to the best of your knowledge, you have not
violated any amateurism rules since you requested a final certification from the NCAA Eligibility
Center or since the last time you signed a Division I student-athlete statement, whichever occurred
later.

You affirm that since requesting a final certification from the NCAA Eligibility Center, you have
not provided false or misleading information concerning your amateur status to the NCAA, the
NCAA Eligibility Center or the institution's athletics department, including administrative
personnel and the coaching staff.

Name (please print) Date

Signature of student-athlete
Student-Athlete Statement Division I
Form 17-1a
Page No. 5
_________

Part IV: Results of Drug Tests.

1. Future positive test all student-athletes sign.

Should I test positive by the NCAA and/or by a non-NCAA athletics organization that has
adopted the World Anti-Doping Agency (WADA) code, or violate their drug-testing protocol or
fail to show for a drug test, at any time after I sign this statement, I acknowledge I must report the
results to my director of athletics.

Name (please print) Date

Signature of student-athlete

2. Positive test by NCAA or non-NCAA athletics organization -- sign either A or B.

A. No positive drug test.

I affirm that, I have never tested positive by the NCAA and/or by a non-NCAA athletics
organization that has adopted the WADA code, nor violated the drug-testing protocol or
failed to show for a drug test conducted by the NCAA or a non-NCAA athletics
organization.

Name (please print)

Signature of student-athlete Date

B. Positive drug test.

I have tested positive by the NCAA and/or by a non-NCAA athletics organization that has
adopted the WADA code, or have violated the drug-testing protocol or failed to show for a
drug test conducted by the NCAA or a non-NCAA athletics organization. If I transfer to
another institution, I am also obligated to report this information to that institution.

Name (please print)

Signature of student-athlete

Date of test Organization conducting test Substance

Are you currently under such a drug-testing suspension? Yes No


Student-Athlete Statement Division I
Form 17-1a
Page No. 6
_________

Part V: Incoming Transfers Previous Involvement in NCAA Rules Violation(s).

Have you previously attended a four-year NCAA Division I, II or III institution?

Yes No

If yes, what is the name(s) of the institution(s)?

Are you aware of any NCAA violations you were involved in while previously attending an NCAA
institution?

Yes No

If yes, did this violation result in you being withheld from competition while attending your previous
institution?

Yes No

If you answered yes to either of the above questions, please provide an explanation.
Student-Athlete Statement Division I
Form 17-1a
Page No. 7
_________

Part VI: Incoming Freshmen Affirmation of Valid ACT or SAT Score.

You affirm that, to the best of your knowledge, you have received a validated ACT and/or SAT
score. You agree that, in the event you are or have been notified by ACT or SAT of the
possibility of an invalidated test score, you will immediately notify your director of athletics (or
his or her designee). You affirm that all information provided to the NCAA, the NCAA
Eligibility Center and institution's admissions office is valid and accurate, including high school
attendance, completion of coursework and high school grades. You affirm that you did not
fraudulently earn your qualifying ACT or SAT score by having someone else take the test for
you, copying answers from another person taking the test, etc.

Name (please print) Date

Signature of student-athlete

What to do with this form: Sign and return it to your director of athletics or his or her
designee before your first competition. This form is to be kept in the director of athletics'
office for six years.

Any questions regarding this form should be referred to your director of athletics or
your institution's NCAA compliance staff or you may contact the NCAA at
317-917-6222.

NCAA/6_13_2017/AR:dks

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